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Upper Gastrointestinal (GI) Bleeding Due to Gastric Ulcer

Author: V. Dimov, M.D.
Reviewer: S. Randhawa, M.D.

A 68-year-old African American male (AAM) was admitted to the hospital with a chief complaint (CC) of emesis of bright red blood. The patient reported that he was shopping when he began throwing up blood at the store. He denied any associated pain, melena, hematochezia, liver disease, or prior episodes. The patient reported some lightheadedness with standing, but denied chest pain (CP), shortness of breath (SOB), and visual disturbances.

He had been taking indomethicin for gout and reported a recent admission 3 months ago for evaluation of occult bleeding, with colonoscopy and upper endoscopy, which did not show ulcers or active bleeding. The patient also denied abdominal pain, chest pain, cough and diarrhea.

Past medical history (PMH)

Gout, hypertension (HTN), anemia.

The review of medical records showed that he had a gout flare up while in the hospital 3 months ago and was discharged home with a steroid taper. He was prescribed indomethacin 50 mg po q 8 hr prn pain but he was taking it daily for the last month.

What happened next?
The Patient was admitted to MICU. The EGD showed a bleeding gastric ulcer which was cauterized and the bleeding stopped. He required 2 more units of RBC and Hgb increased to 9.0 mg/dL.

Prevacid 60 mg bolus was given and he was placed on Prevacid IV drip at 6 mg/hr for 72 hours. He was transferred to a regular medical floor (RMF) and clear liquids diet was started.

Antibiotic treatment for Helicobacter pylori was started before discharge. FeSO4, vit. C and MVT were also added.

Final diagnosis

Upper GI bleeding due to gastric ulcer.

His gastric ulcer was secondary to:

- Helicobacter pylori infection
- Indomethacin
- Steroids

What did we learn from this case?

Helicobacter pylori infection needs to be treated aggressively especially in patients with other risk factors for PUD such as NSAIDs use.

Three regimens consistently eradicate Helicobacter (90 percent) when treatment duration is 10 to 14 days. The treatment of choice is triple therapy with a proton pump inhibitor, amoxicillin and clarithromycin for two weeks. One example is OAC = Omeprazole, Amoxicillin, Clarithromycin. The first attempt to eradicate H. pylori fails in 5 to 12 percent of patients.

If an upper endoscopy is performed and thestomach and proximal intestine is full of fresh andclotted blood, unableto adequately visualize the gastric or duodenal mucosa, and a nasogastric tube isplaced, but the thick blood and clots are difficult toaspirate through the tube, many doctors use IV erythromycin to promote gastric emptying. How about your experience?ThanksAlexandre Benedito Neves Rodrigues, São Paulo- Brazil.endoscopic visualization in many patients.

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